Measuring Processes of Integrated Care for Hospital to Home Transitions

CONCEPTUAL FOUNDATION	HOLLANDER AND PRINCE ENHANCED CONTINUING CARE FRAMEWORK (ECCF) [24]	KODNER AND SPREEUWENBERG [14]	RAINBOW FRAMEWORK [25]
*Biopsychosocial approach*	Principle: “A commitment to the psychosocial model of care” (p. 46). Physical and mental health service integration is needed.	“Integration of knowledge and working methods in general medical practice is necessitated by the bio-psychosocial nature of illness.” (p. 2)	A core value is the “integration of the biomedical, psychological and social dimensions of health and well-being.” (p. 8)
Horizontal integration (integrating health and social systems of care)	Social and health services need to be coordinated and linked.	Integrated care relates to the provision of health care, social services and related supports.	“Vertical- and horizontal integration through inter-sectorial partnerships across the health and social service system is needed.” (p. 9)
Vertical integration (integrated health systems from primary to tertiary)	Levels of health care, from primary through to tertiary/quaternary need to be coordinated and linked.	Integration occurs within and between the cure and care sectors.	“Both vertical and horizontal integration are needed to counteract the fragmentation of services in a health system” (p. 4)
*Patient-centredness*	A clinical best practice is the involvement of clients and families. In particular, ensuring clear information provision and communication.	Integrated care is patient-centric: “characteristics and needs of specific patient groups and their ‘fit’ (or lack thereof) with existing systems of care and cure more or less determine the what, how, and where of integration.” (p. 5)	An important feature of integrated care is person-focused care, which is based on “personal preferences, needs, and values which is in contrast to a disease-focused view.” (p. 4)

Conceptual Framework for Integrated Care for Care Transitions.

Table 2

Domains and Features of Integrated Care Transitions.

DOMAIN OF INTEGRATED CARE TRANSITION CARE	FEATURES OF INTEGRATED CARE TRANSITIONS FROM HOSPITAL TO HOME
Coordinating care between hospital and community	When someone is admitted to hospital, their chronic care delivery is conducted by a multidisciplinary team following a care pathway or guideline [27, 28, 32].
	When someone is admitted to hospital, their care information is transferred to the hospital using a standardized procedure [27, 31].
	On admission to hospital, information is shared on the person’s health and social care between the community and the hospital [27].
	The person receives care from a care coordinator that can provide care across settings [27, 28, 31, 32].
	The person receives care from a case manager that provides care in any setting [27, 28, 31, 32].
	The primary care physician is involved in the care during the person’s hospitalization [27, 28].
	While the person is in hospital, there is regular communication between community agencies involved in the persons’ care and the hospital [27].
	When someone is discharged to community, their written discharge care plan is transferred from hospital to community using a standardized procedure [27, 31].
	Prior to, or within 48 hours of hospital discharge, the person’s individualized care plan is communicated to community providers [27, 32].
	The discharge information for community providers includes the social situation and plan to support community care provision [32].
	Cross-boundary person-specific education or training between health care providers is provided [27].
	Follow-up appointments with primary care provider and others are in place at time of discharge [27, 30].
	Post-hospital support is provided within 48 hours of discharge to ensure needs being met and determine new needs [27, 32].
Interdisciplinary individualized care	The person receives care from a multidisciplinary team providing care across settings [27].
	The person received multi-domain assessment of discharge needs and a plan to meet these needs in hospital [27, 28, 32].
	Hospital disposition planning by a multidisciplinary team follows a care pathway or guideline [27, 28, 32].
Within-hospital coordination	The person’s risk is assessed to determine the level of care transition support needed during hospitalization [27, 32].
	The client has provider continuity during the hospital stay, by means of an assigned care coordinator [27, 31].
	The person’s health and social care needs for discharge is discussed at regular multidisciplinary meetings [27].
Patient involvement in care and care planning	The person and their family are involved in the discharge planning process [27, 30, 31].
	The person and their family’s preferences are incorporated into the discharge plan to ensure their satisfaction [28, 30].
	Client and family provided with education about reason for medical stay and self-care instructions to follow on discharge [27, 28].
	The discharge instructions are individualized to the person’s knowledge needs to ensure understanding [19, 25].
	Client is referred to a post-discharge self-management program [28, 32].
	Client’s discharge care needs are met regardless of program eligibility requirements [32].

Table 3

Results of integrated care items from chart review.

ITEM	% PATIENTS WHO MET ITEM
Coordinating Care between Hospital and Community
1. There is a community care coordinator actively involved in the client’s care as measured by recent community assessment available.	57.8
2. The client has a primary care physician (PCP) that is recorded upon hospital admission.	70.6
3. While the person is in hospital, there is communication between community agencies involved in the persons’ care and the hospital (excluding home care).	27.1
4. Discharge summary was cc’ed to the PCP or receiving institution.	56.6
5a. Prior to, or within 48 hours of hospital discharge, the person’s discharge summary is available for receiving institution/care provider.	29.0
5b. Prior to, or within 48 hours of hospital discharge, the person’s discharge prescription is faxed directly to pharmacy.	70.1
6. Follow-up appointments with primary care provider are in place at time of discharge for those going home.	32.2
7. Cross-boundary person-specific education or training between hospital and community health care providers is provided for discharge care.	0.05
8. All post-hospital recommended home care in place upon hospital discharge.	76.2
Interdisciplinary Individualized Care
9. Preadmission, the client received care from a community-based or boundary-crossing multidisciplinary team.	22.0
10. The person’s risk is assessed to determine the level of care transition support needed during hospitalization (using hospital discharge screening tool).	77.5
11. The client receives a multi-domain assessment of discharge needs in hospital (multidisciplinary team working with client includes both social and health care professionals).	80.8
Within-Hospital Coordination
12. Disposition planning of multidisciplinary follows a care pathway or guideline (as developed with discharge risk tool).	36.0
13. The person’s health and social care needs for discharge is discussed at regular multidisciplinary meetings.	76.6
Patient Involvement in Care Planning
14. The discharge plan is discussed with the family.	69.7
15. Client provided with written discharge information form.	81.6
16. The discharge instructions are free of jargon.	46.1